Patient Screening Form

    Date of in-office screening

    Did you receive your final (or second) vaccination dose more than 14 days ago?

    Screening Questions

    Have you travelled outside of Canada in the past 14 days?

    Have you had close contact with a confirmed case of COVID-19 without wearing appropiate PPE?

    Do you have any of the following symptoms:

    • Fever and/or chills

    • New onset of cough

    • Worsening chronic cough

    • Shortness of breath

    • Decrease or loss of sense of taste or smell

    • If adult >18 years of age: unexplained fatigue/ lethargy/ malaise/ muscle aches (myalgias)

    • If child <18 years of age: nausea/ vomiting, diarrhea

    Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?

    • Any "yes" response must be discussed with the managing dentist immediately.

    • Please follow the steps below before entering our office:

      • Sanitize your hands.

      • Have your temperature taken.

      • Complete a form of acknowledging the risk of COVID-19.

    • Advice to the patient:

      • Only patients are allowed to come to the office.

      • If possible, wait in your car until your appointment, call the office when you arrive.

    Patient Acknowledgement Form

    Please read the patient acknowledgment below, and initial or sign in all areas indicated.

    I understand the SARS CoV-2 virus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the SARS CoV-2 virus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason,I understand that the federal and provincial authorities have recommended that Ontarians exercise caution when leaving home, and otherwise avoid close contact with other people when possible.

    I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.

    I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the SARS CoV-2 virus can spread. I understand that the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

    I understand that due to the visits of other patients, the characteristics of the SARS CoV-2 virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in the dental office

    I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.

    If I received COVID-19 test results in the past three (3) months, the last results I received were negative OR I received a letter from Public Health clearing me.

    If applicable, approximate date of test:

    I confirm that I am not waiting for the results of a test for COVID-19.

    I confirm that this is not currently a period during which public health authorities required I self-isolate.

    I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.

    Patient's Signature: